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Old 06-28-2012
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Default query related to PCOS

query related to PCOS


if patient presents with amenorrhea and start workup. what will be the result of Progesterone challenge test on PCOS ?

there is chronic anovulation in PCOS so will there be withdrawal bleeding ?
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Old 06-29-2012
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Originally Posted by tyagee View Post
query related to PCOS


if patient presents with amenorrhea and start workup. what will be the result of Progesterone challenge test on PCOS ?

there is chronic anovulation in PCOS so will there be withdrawal bleeding ?

there should be withdrawal bleeding ....what do u think .....???
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I too think because E assay is high in PCOS. But not sure.
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I think E assay will be high, problem with PCOS is constant amount of hormone, and no fluctuation.

I felt I understood it better by learning how treatment resolves PCOS rather then just pathophys.
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Progesterone Withdrawal Test - Progesterone Challenge:
A Diagnostic Test for Secondary Amenorrhea:
A positive response is any bleeding more than light spotting that occurs within 2 weeks after the progestin is given. This bleeding will usually occur 2-7 days after the progestin is finished.

Withdrawal bleeding will usually be seen if the patient's estradiol level has been over about 40 pg/ml.

Quote:
Possible Outcomes of the Test
If the patient experiences bleeding after the progestin she has estrogen present but is not ovulating (anovulation).
If no withdrawal bleeding occurs, either the patient has very low estrogen levels or there is a problem with the outflow tract such as uterine synechiae (adhesions) or cervical stenosis (scarring).

Women with Withdrawal Bleeding
The test has demonstrated that she builds up a lining in the uterus.
She bleeds after progesterone is withdrawn - showing that it is the lack of ovulation that is causing her not to have periods.

Possible Diagnoses for Women with Withdrawal Bleeding
Anovulation
Polycystic Ovarian Disease (PCOS)

Women without Withdrawal Bleeding
Possible Diagnosis

Hypothalamic hypoestrogenism (low estrogen levels)
Compromised outflow tract - either Asherman's syndrome (adhesions) or cervical stenosis (scarring)
Premature ovarian failure

The Next Step: Give Estrogen and Progestin to Distinguish Between Hypoestrogenism or an Outflow Tract Obstruction (Asherman's Syndrome or Cervical Stenosis)

Give estrogen to ensure endometrial proliferation, followed by a progestin to induce withdrawal bleeding.

If bleeding occurs, amenorrhea is due to hypoestrogenism (hypothalamic amenorrhea or premature ovarian failure).

If bleeding does not occur, then most likely it is an outflow tract obstruction - either Asherman's syndrome or cervical stenosis.

Last edited by Novobiocin; 06-29-2012 at 09:46 AM.
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Chronic anovulation should be managed by periodic progestin withdrawal, or oral contraceptive pills if the patient does not currently desire pregnancy.

If she desires pregnancy, induction of ovulation with clomiphene citrate or injectable gonadotropins can be considered.

If the anovulatory state has been longstanding, endometrial biopsy should be considered to rule out significant hyperplasia or carcinoma of the endometrium.

Quote:
FSH testing
If the patient did bleed after the combined hormonal regimen (or if that step was skipped) the next test to obtain is an FSH level. This should not be drawn for about 2 weeks after the estrogen-progestin regimen is completed so that the hormone levels are not affected by the medications.

FSH Levels Indicating Ovarian Failure

If the FSH is greater than 30-40 MIU/ml, the patient probably has ovarian failure.

Midcycle FSH peak levels in ovulatory cycles should not be this high.

FSH levels that are menopausal should be checked again in a few weeks for confirmation.

An estradiol level can also be done. With ovarian failure, estrogen is low (less than 20-40 pg/ml).

Ovarian Failure (Premature Menopause)

Once ovarian failure is confirmed, consideration should be given to 3 possibilities:

Mosaicism involving a Y chromosome
Fragile X syndrome
Autoimmune disease

Hypothalamic Amenorrhea
Patients who do not bleed after the progestin challenge but do bleed after estrogen/progestin and have normal or low FSH and LH levels have hypothalamic amenorrhea.

Hypothalamic dysfunction results in abnormal release of LH and FSH hormones from the pituitary. The end result is a lack of proper follicle development and ovulation.

Possible Causes of Hypothalamic Amenorrhea

Some medications (e.g. phenothiazines) as well as extremes of weight loss, stress or exercise can cause this type of secondary amenorrhea.

A pituitary or hypothalamic tumor would be a rare finding in these patients who were all screened with prolactin levels at the beginning of the diagnostic evaluation. However, if there is no cause apparent from the history, it is sometimes suggested to get a baseline CT or MRI scan of the sellar region to rule out a (very rare) tumor.

Hypothalamic Amenorrhea of Uncertain Etiology

Patients with normal prolactin levels and normal imaging studies have hypothalamic amenorrhea of uncertain cause. If amenorrhea and lack of withdrawal bleeding persists, prolactin levels should be measured annually since a small microadenoma could be "hiding".

Treating Amenorrhea Caused by Anorexia Nervosa

Weight loss as a result of anorexia nervosa is an important diagnosis to make because of the mortality rate of 5-15%. Psychiatric counseling is indicated in most cases.

In this condition, as well as in the other hypothalamic amenorrhea situations, the patients can be significantly hypoestrogenic (a low estrogen situation similar to menopause).

Treatments

If the state is persistent, hormone replacement therapy should be considered for protection against osteoporosis.

One approach is to get an estradiol level and if it is less than 30 pg/ml, counsel the patient that hormonal replacement therapy is indicated.
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